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Flashcards in Rheum Deck (20):
1

Methotrexate

7.5 mg, once a week. can combine with DMARDS, antiinflammatory, slows RA progress, dihydrofolate reductase inhibitor, can give IV via PO (cheaper), reassess at 6-12 weeks, titrate up q 2-4 weeks, follow renal and liver (esp CKD) if Cr>1.5, NEVER use. always use folic acid (1 mg), red liver and pulm toxicity (5%), dec. n/v, check CBC (bone marrow) watch LFT (NO etoh, inc risk). cbc, lft, cr and CXR prior to starting. hep a,b,c, hiv, ppd after starting. cbc lft q 4-8 wks, cr every time you check albumin. no sulfamethazole. male or female, 3 month rule for pregnancy. glucocorticoid start bridge temporarily, helps with pain and inflammation, as low as possible.

2

mild RA

no TNF inhibitors, use other agents

3

hydrochloroquine

DMARD, watch for retinal toxicity, see opthamologist at 6 mo, effective on mild form

4

sulfasalazine

DMARD, good for mild disease, exp IBD good option, watch bone marrow suppression (CBC), are they tolerating GI issues, effective mostly on mild form

5

azathioprine

good for IBD, if over 65 and renal insufficiency, good option, can't use MTX or sulfasalazine, not most effective but effective enough, watch for drug-drug interaction, ALLOPURINOL,

6

cyclophosphamide

used in severe vasculitis, extra-articular involvement, not first line, adjust dose for renal insufficiency, infertility with high doses, greater r/f malignancy, can cause hemorrhagic cystitis, take in am with lots of water

7

D-penicilimide

for long-term, poorly controlled, bone marrow suppression, rash, nothing tastes good/metallicky, good for persistent symptoms, weight loss, associated with lupus. 125-250 once a day up to 1g/day

8

leflunomide

like azothioprine but better, immunosupportive, antiinflammatory, liver function toxicity (rare), low SE profile, long half-life, if wanan get pregnant must wait months and months, take chorostylamine for 2 weeks, decreases hepatic absorption and pregnancy can happen sooner (must be undetectable first)

9

TNF alpha antagonists

Adalimumab (Humira), Etanercept (Enbrel), Infliximab (Remicade), Certolizumab (Cimzia), Golimumab (Simponi), good drug, good efficacy

10

Interleukin-1 antagonist

Anakintra (Kineret), not very effective, not used often

11

Suppress T-Cell activation

Abatacept (Orencia), very effective, try if TNF inh doesn't work

12

Anti-B-cell monoclonal antibody

Rituximab (Rituxan), very effective, try if TNF inh doesn't work

13

Infliximab

chimeric, 25% mice, the less mice the better outcome, can develop antibodies, essentially a very expensive placebo, must be infused every 4-8 weeks, avoid this. bind and neutralize membranes and circulating tnf

14

if tnf-a inh is all human

better, no antibodies. can give SQ, easier to give but weekly

15

rituximab

b-cell mediated, 3rd or 4th line treatment, causes destruction of b-cells, causes compliment cascade, lots of SE, non-selective

16

tnf

cornerstone of necrosis of the joint, necrosis/ erosion, pain and inflammation, cartiledge damage, dec joint space narrowing

17

ctla4ig-activators

abatacept-decrease form of auto-immune disease. t and b cells leave the synovial area alone, 4th or 5th line drug, very exp

18

tozilicumab, IL-6 inhibitor

little weak, not used often, mediator of chronic inflammation,

19

Biologics: Relative Contraindications

Active Hep B Infection
MS, optic neuritis
Active serious infections
Chronic or recurrent infections
Current neoplasia
History of TB or positive PPD (untreated)
CHF (class III or IV)

20

Safety considerations with biologic DMARDS

serious infection
opportunistic inf (TB)
malignancies/lymphoma
demylenination
hematologic abnormalities
admin reactions
CHF
Hepatic
autoantibodies and drug induced lupus
vaccination